Treatment of lateral node metastasis from lower rectal cancer

Lateral lymphatics of the rectum originate in the area where branches of the inferior hypogastric plexus and the middle rectal vessels from the internal iliac vessels enter the mesorectum below the level of the peritoneal reflection in the pelvis, then reach the bifurcation of iliac vessels along the internal iliac vessels. Among lateral lymph nodes, the middle rectal, obturator, and internal iliac lymph nodes are important from the viewpoint of both the incidence of metastais and treatment effects. Although total mesorectal excision (TME) had become the standard surgical treatment for rectal cancer by the 1990s, this technique does not treat lateral node metastasis. A randomized clinical trial of TME versus D3 lymphadenectomy (JCOG0212) was started in 2003, and the registration of 701 patients with lower rectal cancer was completed in August 2010. The results of this clinical trial are highly anticipated. In Japan, where the rate of local recurrence after surgery is low, patients at high risk of local recurrence such as those with lateral node metastasis, T4 disease, and multiple lymph node metastases in the mesorectum should be selected to receive preoperative chemoradiation. Japanese surgeons who treat rectal cancers are in an advantageous position because they have the additional measure of lateral node dissection along with TME and chemoradiotherapy.     

Lateral pelvic lymph node dissection for low rectal cancers: A review on current practice

The management of rectal cancer with lateral lymph node involvement is distinctly different between Japan and Western countries. In Japan, total mesorectal excision (TME) surgery followed by autonomic nerve‐preserving lateral pelvic lymph node dissection (LPND) is the standard surgical treatment, whereas in Western countries, patients are subjected to neoadjuvant cheomoradiotherapy followed by TME surgery. The present study aims to explore the current practice and role of LPND in rectal cancer.     

Laparoscopic extended lateral pelvic node dissection following total mesorectal excision for advanced rectal cancer: initial clinical experience

Aim  

To evaluate the technical feasibility, safety, and oncological outcomes of laparoscopic extended lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in patients with advanced low rectal cancer.     

Outcome of lateral pelvic lymph node dissection with total mesorectal excision in treatment of rectal cancer: A systematic review and meta-analysis

BackgroundTotal mesorectal excision is the gold standard treatment of mid- and low-lying rectal cancer. Lateral pelvic lymph node dissection has been suggested as an approach to decrease recurrence and improve survival. Our meta-analysis presented here aimed to review the current outcomes of lateral pelvic lymph node dissection and total mesorectal excision in comparison with total mesorectal excision alone.MethodsA systematic literature search querying electronic databases was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We reviewed articles that reported the outcomes of lateral pelvic lymph node dissection combined with total mesorectal excision in comparison with total mesorectal excision alone. The main outcome measures were local recurrence, distant metastasis, overall and disease free-survival, and complications.ResultsThis systematic review included 29 studies of 10,646 patients. Of those patients, 39.4% underwent total mesorectal excision with lateral pelvic lymph node dissection. The median operation time for the lateral pelvic lymph node dissection + total mesorectal excision was significantly longer than total mesorectal excision alone (360 minutes versus 294.7 minutes, P = .02). Lateral pelvic lymph node dissection + total mesorectal excision was associated with higher odds of overall complications (odds ratio = 1.48, 95% confidence interval: 1.18–1.87, P < .001) and urinary dysfunction (odds ratio = 2.1, 95% confidence interval: 1.21–3.67, P = .008) than total mesorectal excision alone. Both groups had similar rates of male sexual dysfunction (odds ratio = 1.62, 95% confidence interval: 0.94–2.79, P = .08), anastomotic leakage (odds ratio = 1.15, 95% confidence interval: 0.69–1.93, P = .59), local recurrence (hazard ratio = 0.96, 95% confidence interval: 0.75–1.25, P = .79), distant metastasis (hazard ratio = 0.96, 95% confidence interval: 0.76–1.2, P = .72), overall survival (hazard ratio = 1.056, 95% confidence interval: 0.98–1.13, P = .13), and disease-free survival (hazard ratio = 1.02, 95% confidence interval: 0.97–1.07, P = .37).ConclusionLateral pelvic lymph node dissection was not associated with a significant reduction of recurrence rates or improvement in survival as compared with total mesorectal excision alone; however, LPLND was associated with longer operation time and increased complication rate.     

Oncological outcome after lateral pelvic lymphadenectomy for low rectal carcinoma: not only an N-status matter

Tumour deposits (TDs), novel pathological entities, should be considered when estimating the regional and systemic spread of rectal carcinoma and formulating treatment strategies. In fact, TDs may have more severe prognostic impact than lymph node positivity or the lymph node ratio. The assessment of the presence of TDs can be performed only through accurate postoperative pathological examination; however, the detection of TDs is not part of any of the procedures currently used to assess preoperative or intraoperative staging. This review aims to analyse and discuss the impact of TDs on the oncological outcome of patients who undergo surgery for advanced low rectal carcinoma. No prospective study has evaluated the impact of lateral pelvic TDs on oncological outcomes following total mesorectal excision with lateral pelvic lymphadenectomy. Although adequate total mesorectal excision allows for the excision of intramesorectal TDs, lateral pelvic lymph node dissection cannot guarantee the removal of lateral pelvic TDs; moreover, it remains to be determined whether surgical excision of lateral pelvic TDs can impact long-term outcomes. However, the identification of lateral pelvic TDs strengthens the ‘staging effect’ and limits the ‘therapeutic effect’ of lateral pelvic lymphadenectomy, supporting the rationale for the use of neoadjuvant chemoradiotherapy for rectal cancer. When evaluating the oncological outcomes after total mesorectal excision with lateral pelvic lymphadenectomy, the impact of lateral pelvic TDs should be considered.     

Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer

BACKGROUND: Lateral lymph node metastases occur in some patients with low rectal cancer and may cause local recurrence after total mesorectal excision. The aims of this study were to identify risk factors for lateral node metastases in patients with pathological tumour (pT) stage 3 or pT4 low rectal adenocarcinoma, and to evaluate the prognostic significance of lateral node metastases. METHODS: A retrospective analysis was performed of the outcome of 237 patients with pT3 or pT4 low rectal adenocarcinoma who underwent R0 resection with systematic lateral node dissection. RESULTS: Lateral lymph node metastases were found in 41 patients (17.3 per cent). Increased risk of lateral lymph node metastases was associated with a distal tumour margin close to the anal margin, histological type other than well or moderately differentiated adenocarcinoma, and the presence of mesenteric lymph node metastases. Patients with lateral node metastases had a significantly shorter postoperative survival (5-year survival rate 42 versus 71.6 per cent; P < 0.001) and an increased risk of local recurrence (44 versus 11.7 per cent; P < 0.001) compared with those without lateral node metastases. CONCLUSION: Tumour site, histological type and the presence of mesenteric lymph node metastasis are factors predicting the risk of lateral node metastasis. The poor prognosis of patients with lateral lymph node metastases after systematic lateral dissection suggests the need for adjuvant therapy.     

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目的 探讨中下段直肠癌侧方淋巴结转移规律及影响因素。方法 对1995－2000年行侧方淋巴结清扫的105例直肠癌病人进行回顾性分析。结果 中下段直肠癌侧方转移率为21％，肿瘤的大小、部位、病理分型、分化程度及浸润深度是影响侧方转移的重要因素。在侧方淋巴结转移阳性病人中，单纯闭孔及髂内淋巴结转移阳性病人占54．5％，单纯髂外及髂总淋巴结转移阳性病人为18．1％。侧方淋巴结转移阴性病人术后局部复发率为6．7％，阳性病人为36．3％。行侧方清扫局部复发率较传统术式由17．6％降至11．4％。侧方转移阴性病人平均生存期为88个月，阳性病人为37个月，二者差异有显著性。结论 侧方淋巴转移是中下段直肠癌淋巴转移的重要途径。闭孔和髂内淋巴结是侧方淋巴结清扫中需要着重清扫的部位。侧方淋巴清扫较传统术式可明显降低局部复发率。     

Survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved

Purpose

The effectiveness of lateral lymph node dissection for extending the survival of patients with advanced lower rectal cancer remains unclear. The purpose of this study was to clarify the survival benefit of lateral lymph node dissection according to the region of involvement and the number of lateral lymph nodes involved.

Methods

We reviewed 131 consecutive patients with advanced lower rectal cancer, who had undergone curative resection with total mesorectal excision plus extended lateral lymph node dissection at Wakayama Medical University Hospital. Twenty-six (19.1 %) of these patients had lateral lymph involvement. We performed univariate and multivariate analyses for the 3-year disease-free and overall survival of these patients.

Results

Multivariate analysis revealed that the number (>1) and the region (common iliac artery region or external iliac artery region) of lateral lymph node metastasis are independent predictive factors for recurrence and survival. The Kaplan–Meier analysis demonstrated that patients with one lymph node metastasis in the internal iliac artery or obturator region had better survival.

Conclusions

Lateral lymph node dissection resulted in survival benefit for patients with single lateral lymph node involvement in the internal iliac artery region or the obturator region.     

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??Lateral lymph node dissection via lateral vascular approach with en-bloc dissection of laparoscopic total mesorectal excision for advanced middle and low rectal cancer LIANG Jian-wei, LIU Qian, ZHOU Si-cheng, et al. National Cancer Center & National Clinical Research Center for Cancer & Cancer Hospital??Chinese Academy of Medical Sciences and Peking Union Medical College??Beijing 100021??China
Corresponding authors: LIU Qian??E-mail: fcwpumch@163.com??WANG Xi-shan??E-mail: wxshan1208@126.com
Abstract Objective To investigate the feasibility and safety of the en-bloc resection via lateral vascular approach combined with lateral lymph node dissection (LLND). Methods The clinical and pathological data of 72 cases of laparoscopic total mesorectal excision resection of rectal cancer combined with LLND via lateral vascular approach were retrospectively analyzed. There were 38 cases of preoperative chemoradiotherapy??9 patients with neochemotherapy??25 cases without preoperative treatment. All patients were diagnosed with lateral lymph node metastasis by MRI or PET-CT before treatment. The first step of LLND was performed by the distal of external iliac artery??then high ligation the inferior mesenteric vascular and opened the left Toldt’ space??and the final step was the total mesorectal excision. All of the spacemen were en-bloc dissection of the later lymph node with the rectal cancer. Results There were 19 cases of bilateral LLND??28 cases with unilateral left LLND??25 cases on the right side. The harvested pelvic lymph node detection was 8.3??19.4% of lateral lymph node metastasis rate??14/72????12 cases of unilateral lateral lymph node metastasis??2 cases of bilateral metastasis??and 7 patients combined viscera resection??9.7%??. The operative time was 281.4??145~600??min and the intraoperative blood loss was 89.7??30~1200??mL. A total of 11 cases??15.3%??had surgical complications and no surgical death. The positive rate of lateral pelvic lymph node in preoperative chemoradiotherapy patients was 23.7% ??9/38????and 22.2%??2/9??in the neochemotherapy group. Conclusion Laparoscopic resection of rectal cancer combined with LLND via transvascular lateral approach is safe and feasible??and not increase in operative complications.     

盆腔侧方淋巴结转移对低位直肠癌预后的影响

目的 探讨盆腔侧方淋巴结转移对低位直肠癌预后的影响.方法 对1994年至2005年行根治性切除联合盆腔侧方淋巴结清扫的176例低位直肠癌患者的资料进行回顾性分析.探讨低位直肠癌患者盆腔侧方淋巴结转移对其预后的影响.结果 全组盆腔侧方淋巴结转移33例(18.8%),其中髂内及直肠中动脉根部淋巴结转移占51.5%,闭孔淋巴结转移占39.4%.年龄≤40岁、浸润型癌、T3-4期、上方淋巴结转移患者的盆腔侧方淋巴结转移率较高(P＜0.05).全组5年生存率为64.1%,TNM分期Ⅰ、Ⅱ、Ⅲ期患者5年生存率分别为94.1%、79.1%、42.1%.癌灶大小、浸润深度、上方淋巴结转移、盆腔侧方淋巴结转移是影响低位直肠癌患者预后的重要因素(P＜0.05).盆腔侧方淋巴结阴性患者5年生存率为73.6%,而侧方淋巴结转移患者为21.4%,两组差异具有统计学意义(P＜0.05).结论 盆腔侧方淋巴结转移是影响低位直肠癌预后的重要因素.     

经血管外侧入路腹腔镜中低位直肠癌侧方淋巴结清扫72例临床分析

目的 探讨血管外侧入路腹腔镜直肠癌侧方淋巴结清扫（LLND）的可行性和安全性。方法 回顾性分析2016年10月至2018年6月中国医学科学院肿瘤医院收治的行经血管外侧入路腹腔镜直肠癌LLND的72例病人的临床资料。术前同步放化疗38例,术前单纯化疗9例,25例术前未进行治疗,治疗前均经MRI或PET-CT检查诊断为侧方淋巴结转移。采用经髂外动脉远端入路行淋巴结清扫,高位结扎切断肠系膜下动脉并按全直肠系膜切除原则行直肠癌根治术,所有病人均完成清扫后再完成直肠切除,标本均达到整块切除。结果 19例病人行双侧LLND,28例行左侧LLND,25例行右侧LLND。平均侧方淋巴结检出数目为（8.3±6.2）枚;侧方淋巴结转移14例（19.4%）,其中单侧转移12例,双侧转移2例。联合器官切除7例。手术时间为281.4（145~600）min,术中出血89.7（30~1200）mL。11例（15.3%）病人出现手术并发症,无手术死亡。术前同步放化疗病人侧方淋巴结阳性率为23.7%（9/38）,术前单纯化疗病人侧方淋巴结阳性率为22.2%（2/9）。结论 血管外侧入路腹腔镜中低位直肠癌LLND不增加手术并发症,安全可行。     

Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection

OBJECTIVE: To identify the parameters related to the effective selection of patients who could receive prognostic benefit from lateral pelvic node dissection. BACKGROUND: Accurate preoperative diagnosis of lateral nodal involvement (LNI) remains difficult, and the indications for lateral lymph node dissection have been controversial. PATIENTS AND METHODS: A total of 244 consecutive patients who underwent potentially curative surgery with lateral dissection for advanced lower rectal cancer (1985-2000) were reviewed. Patients were stratified into groups based on various parameters, and the therapeutic value index for survival benefit was compared among groups. The therapeutic index of lateral dissection was calculated by multiplying the frequency of metastasis to the lateral area and the cancer-related 5-year survival rate of patients with metastasis to the lateral area, irrespective of metastasis to other areas (mesorectal, superior rectal artery [SRA], and inferior mesenteric artery [IMA] areas). RESULTS: LNI was observed in 41 patients (17%); and 88% of them had nodal involvement in the region along the internal iliac/pudendal artery or in the obturator region ("vulnerable field"). The cancer-related 5-year survival rate among the patients with LNI was 42%; the therapeutic index for lateral dissection was calculated as 7.0 patients, which was much higher than that of lymphadenectomy of the SRA area (1.6 patients) and the IMA area (0.4 patients), and almost comparable to that of lymphadenectomy of the upward mesorectal area (6.9 patients). Although it was possible to select groups at high and low risk for LNI based on several parameters related to tumor aggressiveness, such as tumor differentiation in biopsy specimens, the therapeutic value index was not significantly different between these groups. Unlike these parameters, the diameter of the largest lymph node in the "vulnerable field," which was positively correlated with the rate of LNI but irrelevant to the prognosis, was able to successfully stratify patients by therapeutic index. CONCLUSIONS: Advanced lower rectal cancer patients having LNI in the lateral pelvic area are likely to receive prognostic benefit from lymphadenectomy. The most efficient means of determining the effectiveness of lateral dissection preoperatively is to estimate the nodal diameter in the "vulnerable" lateral regions by diagnostic imaging.     

直肠癌侧方淋巴结清扫的个性化治疗策略

随着全直肠系膜切除术和新辅助放化疗的广泛应用,中低位直肠癌患者的预后明显改善。近年来随着腹腔镜和机器人手术系统等微创技术应用于直肠癌根治性手术,以及肿瘤分子标志物和基因测序技术的发展,直肠癌治疗已进入个体化精准医疗时代。在这样的时代背景下,关于中低位直肠癌侧方淋巴结清扫必要性的争议愈发引人注目,其包括与新辅助治疗的关系,侧方淋巴结清扫的手术指征、范围及神经保护等多个方面。作为进展期中低位直肠癌重要治疗手段,直面争议,增加侧方淋巴结清扫相关循证医学证据是当务之急。     

低位直肠癌TME原则下侧方淋巴结清除152例

目的：根据低位直肠癌区域淋巴结转移规律,探讨在低位直肠癌治疗中直肠系膜全切除（TME）原则和侧方淋巴结清除范围。方法：收集152例行根治性手术的低位直肠癌患者的临床病理资料,分析区域淋巴结转移情况,遵循TME原则及侧方淋巴结清除方法清除直肠癌区域淋巴结。应用常规病理学方法观察其区域淋巴转移规律。结果：1）侧方淋巴转移是腹膜返折以下直肠癌的转移途径;2）侧方淋巴转移易发生在直肠筋膜后方,并且与浸润深度有关。结论：低位直肠癌应该在TME原则下行侧方淋巴清除,既可以避免转移淋巴结及系膜组织的残留,又可防止过度损伤,提高了生存率,又减少了并发症。     

侧方淋巴结清扫对进展期低位直肠癌预后的影响

目的 应用治疗指数(therapeutic index,TX)(TX=肿瘤相关5年生存率×区域淋巴结转移的概率)评估侧方淋巴结清扣对于改善进展期低位直肠癌预后的价值.方法 回顾性分析直肠癌行根治性切除+全直肠系膜切除+侧方淋巴结清扫的96例进展期低位直肠癌患者的临床资料.结果 进展期低位直肠癌直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移率分别为21%(20/96),13%(12/96),10%(10/96)和15%(14/96).检出直肠系膜淋巴结、直肠上动脉旁淋巴结、肠系膜下动脉旁淋巴结和侧方淋巴结转移阳性的进展期低位直肠癌患者5年生存率分别为35%,25%,20%和36%.TX:清扫直肠系膜淋巴结和侧方淋巴结的TX分别为7.4和5.4,明显高于清扫直肠上动脉和肠系膜下动脉旁淋巴结的3.3和2.0.侧方淋巴结转移阳性者术后局部复发率为64%(9/14),TX明显高于侧方淋巴结转移阴性者的11%(9/82)(x2=22.308/P=0.000).Kaplan-Meier生存分析显示,侧方淋巴结转移阳性患者平均生存期为(38.0±6.7)个月(95%置信区间:24.8～51.2个月),明显短于侧方淋巴结转移阴性的(80.9±2.1)个月(95%置信区间:76.7～85.1个月),两者差异有统计学意义. 结论侧方淋巴结清扫可降低进展期低位直肠癌根治性切除术后局部复发率以及改善预后.除全直肠系膜切除外,进展期低位直肠癌术中还应进行侧方淋巴结清扫.     

膀胱癌盆腔淋巴结转移的规律及影响因素分析

目的通过分析膀胱尿路上皮癌淋巴结转移的规律及其相关影响因素,结合盆腔淋巴清扫的研究进展,探讨盆腔淋巴清扫策略。 方法收集我院2008年至2016年由同一术者完成腹腔镜根治性膀胱切除和盆腔淋巴清扫的膀胱尿路上皮癌患者的资料,回顾性分析淋巴结转移的规律及其相关影响因素。 结果共收集患者285例,69例（24.2%）发生淋巴结转移。最常见的淋巴结转移部位为髂内/闭孔淋巴结（57/69,82.6%）,其次是髂外淋巴结（37/69,53.6%）;真骨盆外淋巴结转移均伴随髂内/闭孔或髂外淋巴结转移;单侧壁膀胱癌可以向对侧盆腔淋巴结转移。T1组淋巴结转移率4.6%（4/87）,T2组18.0%（18/100）;T3组50.8%（30/59）;T4组68.0%（17/25）。多因素回归分析显示淋巴结转移与肿瘤分期呈正相关,与分级、年龄、性别、体质量指数、吸烟等因素无关。 结论髂内/闭孔和髂外淋巴结是膀胱癌最主要的淋巴结转移部位,肿瘤高分期是影响膀胱癌淋巴结转移的主要因素。根治性膀胱切除术应行至少包括双侧髂内、闭孔、髂外淋巴结的标准淋巴清扫。     

Comparative outcome between chemoradiotherapy and lateral pelvic lymph node dissection following total mesorectal excision in rectal cancer

OBJECTIVE: To evaluate comparative outcome between adjuvant postoperative chemoradiotherapy (postoperative CRT) and lateral pelvic lymph node dissection (LPLD) following total mesorectal excision (TME) in rectal cancer patients. BACKGROUND: Although TME results in lower rate of locoregional recurrence compared with conventional surgery, these 2 treatment modalities following TME have not adequately been appraised until the present trend of preoperative chemoradiotherapy. PATIENTS AND METHODS: Between 1995 and 2000, patients with stage II and III rectal cancer underwent TME plus postoperative CRT (n = 309) or LPLD (n = 176). Patients in the postoperative CRT group received 8 cycles of 5-fluorouracil plus leucovorin and 45 Gy pelvic radiotherapy. Patients in the LPLD group underwent lateral lymph node dissection outside the pelvic plexus. RESULTS: The 5-year overall and disease-free survival rates were 78.3% and 67.3% in the postoperative CRT group, respectively, and 73.9% and 68.6% in the LPLD group, respectively, without significant differences between these groups. Patients in the LPLD group with stage III lower rectal cancer had a locoregional recurrence rate 2.2-fold greater than those in the postoperative CRT group (16.7% vs. 7.5%, P = 0.044). Multivariate analysis showed that APR and advanced T-category (T4) were significantly associated with locoregional recurrence, whereas lymph node metastases, high preoperative serum carcinoembryonic antigen, and APR were significantly associated with shortening of disease-free survival. CONCLUSIONS: Postoperative-CRT and LPLD following TME resulted in comparable survival rates, but the locoregional recurrence rate was higher in the LPLD group. These findings suggest that initial surgery is appropriate for rectal cancer patients who are candidates for low anterior resection without extensive local disease (T1-T3), regardless of lymph node status.     

中低位直肠癌新辅助放疗后系膜内淋巴结隐匿转移的临床病理学研究

目的探讨新辅助放疗后中低位直肠癌系膜内淋巴结隐匿转移及其与临床病理因素的关系。方法74例中低位直肠癌患者接受了新辅助放疗及全直肠系膜切除手术（TME）,术后应用脂肪清除技术获取全部淋巴结．将苏木精-伊红染色无淋巴结转移的标本进一步行抗CK抗体免疫组织化学（免疫组化）染色,检测淋巴结内肿瘤隐匿转移情况,并分析隐匿转移与临床病理因素之间的关系。结果74例标本共检出1883枚淋巴结．每例（25．4±1．3）枚。淋巴结常规病检发现172枚有转移（35例,占47.3％）,其直径（4．9＋2．6）mm,显著大于无转移淋巴结的直径（2．7±1．4）mm（P〈0．01）。对常规病检无转移的1711枚淋巴结进一步行抗CK抗体免疫组化检测．发现其中40枚（2．3％）有隐匿转移（24例,占32．4％）,隐匿转移淋巴结直径（3．2±1．2）mm,显著小于常规病理有转移的淋巴结（P〈0．01）。常规病检淋巴结无转移的39例患者有淋巴结隐匿转移者9例（23．1％）,明显低于常规病检淋巴结有转移者的淋巴结隐匿转移率（15／35,42．8％,P〈0．01）。ypN0期患者淋巴结隐匿转移与否对预后的影响差异无统计学意义（P=0．157）。结论对常规病检淋巴结无转移的直肠癌患者．存在淋巴结隐匿转移不应改变其N分期：不应将淋巴结隐匿转移单独作为TNM分期中对淋巴结转移情况的判断指标。     

中低位直肠癌侧方淋巴引流放射性核素显像的初步研究

目的 探讨放射性核素淋巴显像对中低位直肠癌侧方淋巴结转移的诊断价值。方法 选择1999年5月至2001年3月经病理证实的大肠癌患者32例，以^99m锝-硫胶体(^99mTc—SC)为显像剂，于术前1日行盆腔、下腹部放射性核素淋巴显像。32例中直肠癌27例，乙状结肠癌3例，结肠癌2例。对15例腹膜返折以下直肠癌行侧方淋巴结清扫的扩大根治术，将其显像结果与术后侧方淋巴结病理检查进行对照。结果 直肠旁淋巴结，闭孔淋巴结，髂血管、主动脉淋巴链的显像率分别为69％、91％、100％。行侧方淋巴结清扫的15例直肠癌，其核素显像对称10例，不对称5例。侧方淋巴结病理阳性率13％(2／15)。以图像不对称为显像阳性，结果 表明核素显像的灵敏度为100％，特异度为77％，符合率为80％，。结论 盆腔、下腹部核素显像是术前判断中低位直肠癌侧方淋巴结是否转移的较好方法，此法有助于制定合理的个体化手术方案。     

Lateral Lymph Node Dissection for Lower Rectal Cancer

The mainstay of surgical therapy for rectal cancer is colectomy (including lesions) with lymph node dissection. The lymphatic spread of rectal cancer can proceed in two directions: medially toward the origin of the inferior mesenteric artery or laterally toward the pelvis aslong the internal iliac artery. To prevent postoperative recurrence, lymph nodes situated along these two axes should be adequately dissected, leaving no residual cancer cells. In Japan, the standard procedure for advanced lower rectal cancer is mesorectal excision and lateral lymph node dissection with autonomic nerve preservation. In Europe and North America, lateral lymph node dissection used to be performed, but it led to increased blood loss, complications, and dysfunction, with no improvement in survival. Lateral lymph node dissection is thus no longer performed. Instead, multidisciplinary therapy combining mesorectal excision with preoperative chemoradiotherapy is now the standard treatment for advanced rectal cancer. Although lateral lymph node dissection decreases the rate of local recurrence similar to preoperative chemoradiotherapy, whether it contributes to improved survival remains unclear. In addition, it is unlikely that prophylactic lateral lymph node dissection is required in all patients with rectal cancer. Definition of the indications for lateral lymph node dissection is thus an important concern.